Our highly trained clinicians can help.

If you’ve come across someone who needs the type of help you just don’t feel qualified to give, we can help. Our treatment and services are specifically designed to increase successful outcomes so your patients, your students, your families can live their best lives.

Please fill out our referral form, and help will be on the way.

Prefer to submit by fax or email? Download a PDF version of this form.

About the Client
Client Name*
First Last
Client Email Address
Date of Birth
Primary Phone
Alternate Phone
Primary Phone Message consent
- Check if OK to leave message
Alternate Phone Message consent
- Check if OK to leave message
Contact/Guardian Name
First Last
Contact/Guardian Phone
Contact/Guardian Email
Reason for Seeking Service
Include a known diagnosis, if one exists.
Is the client aware of the referral?
- Yes
- No
About You
Your Name
First Last
Your Email Address
Your Phone
Connection to Client
Please briefly describe

Our highly trained clinicians can help.

About the Client

About You